Provider Demographics
NPI:1427570217
Name:HOUSTON, JOHN WAYNE
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYNE
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 BURNETT AVE S APT 311
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-7510
Mailing Address - Country:US
Mailing Address - Phone:925-698-9002
Mailing Address - Fax:
Practice Address - Street 1:212 WELLS AVE S STE 103
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2142
Practice Address - Country:US
Practice Address - Phone:925-698-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60318778405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional